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Morais CG, Alves I, Coelho J, Vilares AT, Do Bom-Sucesso M. Multifocal Infantile Hepatic Hemangiomas Complicated by Consumptive Hypothyroidism: The Benefits of Early Diagnosis and Treatment. J Pediatr Hematol Oncol 2023; 45:e294-e297. [PMID: 35900056 DOI: 10.1097/mph.0000000000002509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 06/02/2022] [Indexed: 11/26/2022]
Abstract
Infantile hepatic hemangiomas (IHH) account for 12% of all childhood hepatic tumors. Most IHH are diagnosed within the first 6 months of life and involute spontaneously; however, some require medical treatment. The present report describes a case of multifocal IHH associated with subcutaneous and lingual hemangiomas, complicated by consumptive hypothyroidism and successfully managed with oral propranolol and thyroid replacement therapy, without documented adverse effects. Consumptive hypothyroidism is a rare complication of IHH, but suggestive of multifocal/diffuse subtypes. The authors intend to reinforce the importance of early referral to a Vascular Anomalies Center and treatment with propranolol in selected patients.
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Walther A, Häberle B, Küppers J, Lurz E, Schmid I, Schmidt H, Dubinski I. Severe consumptive hypothyroidism in hepatic hemangioendothelioma. J Pediatr Endocrinol Metab 2022; 35:1560-1564. [PMID: 36190305 DOI: 10.1515/jpem-2022-0347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 08/16/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Consumptive hypothyroidism may occur in hepatic hemangioendothelioma. The altered expression of deiodinases inactivates peripheral thyroid hormones. As a result, serum levels of free triiodothyronine and free thyroxine are reduced to varying degrees. There are no established recommendations for the dosage of sirolimus for this particular indication. We describe for the first time the course of treatment with low-dose sirolimus. CASE PRESENTATION We present a 5-week-old infant with hepatic hemangioendothelioma and severe consumptive hypothyroidism. Due to hepatic infiltration he showed signs of right heart strain. Therapy of hemangioendothelioma was initiated with propranolol and, in the absence of response, methylprednisolone was added. Treatment was continued with low-dose sirolimus (due to side effects) and propranolol. Hypothyroidism was managed with levothyroxine and liothyronine. CONCLUSIONS Consumptive hypothyroidism due to cutaneous hemangioma and hepatic hemangioendothelioma can be managed with propranolol and low-dose sirolimus. Treatment of severe hypothyroidism may require a combinational therapy by substitution of both T3 and T4.
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Affiliation(s)
- Antonia Walther
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital Munich, LMU, Munich, Germany
| | - Beate Häberle
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, University Hospital Munich, LMU, Munich, Germany
| | - Julia Küppers
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, University Hospital Munich, LMU, Munich, Germany
| | - Eberhard Lurz
- Division of Pediatric Gastroenterology und Hepatology, Dr. von Hauner Children's Hospital, University Hospital Munich, LMU, Munich, Germany
| | - Irene Schmid
- Division of Pediatric Hematology and Oncology, Dr. von Hauner Children's Hospital, University Hospital Munich, LMU, Munich, Germany
| | - Heinrich Schmidt
- Division of Pediatric Endocrinology and Diabetology, Dr. von Hauner Children's Hospital, University Hospital Munich, LMU, Munich, Germany
| | - Ilja Dubinski
- Division of Pediatric Endocrinology and Diabetology, Dr. von Hauner Children's Hospital, University Hospital Munich, LMU, Munich, Germany
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Siano MA, Ametrano O, Barbato F, Sammarco E, Ranucci G, Pietrobattista A, Rossomando A, Mandato C. Consumptive Hypothyroidism due to Hepatic Hemangiomas: A Case Series and Review of the Literature. JPGN REPORTS 2022; 3:e270. [PMID: 37168485 PMCID: PMC10158424 DOI: 10.1097/pg9.0000000000000270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 10/06/2022] [Indexed: 05/13/2023]
Abstract
Consumptive hypothyroidism (CH) is a rare and potentially overlooked complication of hepatic hemangiomas (HH) overexpressing the enzyme deiodinase, which converts thyroxine (T4) to reverse triiodothyronine (rT3). Materials and methods Here, we report a case series of 3 patients and a systematic review of the literature. Results Hypothyroidism (mean serum TSH 52.03 mIU/L) was detected at a mean age of 4.6 months (range 3-6) in 3 infants with infantile hepatic hemangiomas, treated with thyroxine (mean dose 12 µg/kg/day). All received treatment with propranolol (1-3 mg/kg/day) from the mean age of 4 months. Hormonal treatment was stopped at a mean age of 20 months (range 12-30). Hypothyroidism reoccurred in a patient concurrently with the increase of liver lesions, requiring liver transplantation (LT) at age 39 months.Literature review retrieved 42 studies (48 patients): HH (n = 43) were isolated in 24 infants and associated with cutaneous hemangiomas in 19. Hemangiomas were only cutaneous in 5.In the first 43 patients, hypothyroidism was detected at a mean age of 1 month; 21 of 43 patients were prescribed propranolol alone (n = 8) or associated with other medicaments (n = 13); 2 of 43 patients underwent LT. Hormonal treatment consisted of T4 in 35 of 43 patients and T3 in 10.CH associated with only cutaneous and extrahepatic visceral hemangiomas (n = 5), detected at a mean age of 7 months (TSH mean levels at diagnosis of 150.3 mIU/L). Three of 5 patients received treatment with propranolol ± other medicaments. All 5 patients were treated with T4. Conclusions Periodical thyroid function assessment is necessary in patients with hepatic hemangiomas, particularly when lesions' size and number increase rapidly.
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Affiliation(s)
- Maria Anna Siano
- From the Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, Università di Salerno, Baronissi (Salerno), Italy
| | - Orsola Ametrano
- Department of Pediatric Dermatology, Santobono-Pausilipon Children Hospital, Naples, Italy
| | - Filomena Barbato
- Department of Pediatric Dermatology, Santobono-Pausilipon Children Hospital, Naples, Italy
| | - Elena Sammarco
- Department of Pediatric Dermatology, Santobono-Pausilipon Children Hospital, Naples, Italy
| | - Giusy Ranucci
- Department of Pediatrics, Santobono-Pausilipon Children Hospital, Naples, Italy
| | | | - Alessia Rossomando
- From the Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, Università di Salerno, Baronissi (Salerno), Italy
| | - Claudia Mandato
- From the Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, Università di Salerno, Baronissi (Salerno), Italy
- Department of Pediatrics, Santobono-Pausilipon Children Hospital, Naples, Italy
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Hemangioma Genetics and Associated Syndromes. Dermatol Clin 2022; 40:393-400. [DOI: 10.1016/j.det.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Liu Q, Guo X, He X, Liu N, Shi J, Geng Y, Cao P. Infantile hepatic hemangioma complicated consumptive hypothyroidism. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2021. [DOI: 10.1016/j.epsc.2021.102005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Verma A, Jain R, Babbar N, Kharkongor NP. Multiple infantile hepatic hemangiomas leading to consumptive hypothyroidism successfully treated with propranolol: A case report. J Family Med Prim Care 2021; 9:5759-5762. [PMID: 33532427 PMCID: PMC7842472 DOI: 10.4103/jfmpc.jfmpc_1074_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 09/09/2020] [Accepted: 09/22/2020] [Indexed: 11/04/2022] Open
Abstract
Hepatic hemangioma is a commonly encountered benign vascular tumour of liver during infancy. Acquired hypothyroidism is one of the rare manifestation of this entity. We report a 4-month-old infant born to a diabetic mother who developed acquired hypothyroidism not responding to treatment due to multiple hepatic hemangiomas. The mechanism behind is increased type 3 deiodinase activity due to hemangiomas of liver, which catalyses conversion of T4 to rT3 and T3 to T2. Hemangiomas were successfully treated with propranolol which lead to its regression and ultimately resulted in euthyroidism. Hence, screening for hepatic hemangioma should be done in all cases of congenital hypothyroidism not responding to thyroxine treatment. We also propose early initiation of treatment of hemangiomas with propranolol as the first line therapy to prevent growth retardation and intellectual loss.
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Affiliation(s)
- Anjali Verma
- Departmentof Pediatrics, PGIMS, Rohtak, Haryana, India
| | - Rashika Jain
- Departmentof Pediatrics, PGIMS, Rohtak, Haryana, India
| | - Neha Babbar
- Departmentof Pediatrics, PGIMS, Rohtak, Haryana, India
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Osada A, Araki E, Yamashita Y, Ishii T. Combination therapy of propranolol, levothyroxine, and liothyronine was effective in a case of severe consumptive hypothyroidism associated with infantile hepatic hemangioma. Clin Pediatr Endocrinol 2019; 28:9-14. [PMID: 30745728 PMCID: PMC6356094 DOI: 10.1297/cpe.28.9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 11/01/2018] [Indexed: 11/12/2022] Open
Abstract
Infantile hepatic hemangioma (IHH) can be accompanied by consumptive hypothyroidism. We
report the case of a 4-mo-old boy who showed massive hepatomegaly, peripheral coldness,
lethargy, and failure to thrive. An enhanced computed tomography scans demonstrated
multiple hemangiomas in both lobes of the liver, and a thyroid function tests showed
severe hypothyroidism: TSH 561.5 µIU/mL, free triiodothyronine (fT3) 1.0 pg/mL,
and free thyroxine (fT4) < 0.7 ng/dL. IHH gradually regressed following
propranolol treatment and fT4 increased to a low normal level (1.0 ng/dL) by
high dose replacement of levothyroxine, while fT3 remained very low (< 1.0
pg/mL), even following high doses of levothyroxine; fT3 eventually normalized
following the administration of liothyronine. We suggest that treatment strategies should
be individualized based on thyroid function, and that the combination therapy of
propranolol for anti-tumor treatment and levothyroxine and liothyronine for respective
thyroid hormone replacement is effective, particularly in cases of severe consumptive
hypothyroidism due to multiple IHHs.
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Affiliation(s)
- Asami Osada
- Department of Pediatrics, Yokohama Municipal Citizen's Hospital, Yokohama, Japan.,Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Eriko Araki
- Department of Pediatrics, Yokohama Municipal Citizen's Hospital, Yokohama, Japan
| | - Yukio Yamashita
- Department of Pediatrics, Yokohama Municipal Citizen's Hospital, Yokohama, Japan
| | - Tomohiro Ishii
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
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